Data from: Do failures in non-technical skills contribute to fatal medical accidents in Japan? A review of the 2010–2013 national accident reports

Objectives: We sought to clarify how large a proportion of fatal medical accidents can be considered to be caused by poor Non-Technical Skills, and to support development of a policy to reduce numbers of such accidents by making recommendations about possible training requirements. Design: Summaries of reports of fatal medical accidents, published by the Japan Medical Safety Research Organization, were reviewed individually. Three experienced clinicians and one patient safety expert conducted the reviews to determine the cause of death. Views of the patient safety expert were given additional weight in the overall determination. Setting: A total of 73 summary reports of fatal medical accidents were reviewed. These reports had been submitted by healthcare organisations across Japan to the Japan Medical Safety Research Organization between April 2010 and March 2013.
Primary and secondary outcome measures: The cause of death in fatal medical accidents, categorised into technical skills, non-technical skills, and inevitable progress of disease were evaluated. Non-technical skills were further sub-divided into situation awareness, decision-making, communication, team working, leadership, managing stress, and coping with fatigue. Results: Overall, the cause of death was identified as non-technical skills in 34 cases (46.6%), disease progression in 33 cases (45.2%), and technical skills in two cases (5.5%). In two cases, no consensual determination could be achieved. Further categorisation of cases of non-technical skills were identified 14 cases (41.2%) of problems with situation awareness, eight (23.5%) with team-working, and three (8.8%) with decision-making. These three sub-categories, or combinations of them, were identified as the cause of death in 33 cases (97.1%). Conclusions: Poor non-technical skills were considered to be a significant cause of adverse events in nearly half of the fatal medical accidents examined. Improving non-technical skills may be effective for reducing accidents, and training in particular sub-categories of non-technical skills may be especially relevant.

研究目的：本研究旨在明确可归因于非技术技能（Non-Technical Skills）缺失的致命医疗事故所占比例，并通过提出针对性培训需求建议，为制定降低此类事故发生率的相关政策提供依据。
研究设计：对日本医疗安全研究组织（Japan Medical Safety Research Organization）发布的致命医疗事故报告摘要进行独立审阅。由3名经验丰富的临床医师与1名患者安全专家共同完成审阅工作，以判定死亡原因；患者安全专家的意见在最终综合判定中享有更高权重。
研究场景：本次共审阅73份致命医疗事故摘要报告，上述报告由日本全国范围内的医疗机构于2010年4月至2013年3月期间提交至日本医疗安全研究组织。
主要与次要结局指标：对致命医疗事故的死亡原因开展分类评估，将其划分为技术技能、非技术技能以及疾病不可避免进展三类；其中非技术技能进一步细分为情境觉知（situation awareness）、决策制定、沟通协作、团队合作、领导力、压力管理与疲劳应对7个子类别。
研究结果：整体而言，34例（46.6%）事故的死亡原因被判定为非技术技能缺失，33例（45.2%）为疾病进展所致，2例（5.5%）为技术技能问题导致；另有2例未能达成一致性判定。对非技术技能相关案例的进一步细分显示，14例（41.2%）存在情境觉知问题，8例（23.5%）存在团队合作问题，3例（8.8%）存在决策制定问题。上述3个子类别及其组合共覆盖33例（97.1%）非技术技能相关致死案例。
研究结论：在本次纳入研究的致命医疗事故中，近半数案例的不良事件可归因于非技术技能缺失，该因素为重要的致死诱因。提升非技术技能水平或可有效降低医疗事故发生率，针对特定非技术技能子类别的培训或许具备尤为重要的实践价值。